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Galea R, Seiffge D, Räber L. Atrial Fibrillation and Ischemic Stroke despite Oral Anticoagulation. J Clin Med 2023; 12:5784. [PMID: 37762726 PMCID: PMC10532406 DOI: 10.3390/jcm12185784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with atrial fibrillation (AF) experiencing ischemic stroke despite oral anticoagulation (OAC), i.e., breakthrough strokes, are not uncommon, and represent an important clinical subgroup in view of the consistently high risk of stroke recurrence and mortality. The understanding of the heterogenous potential mechanism underlying OAC failure is essential in order to implement specific therapeutic measures aimed at reducing the risk of recurrent ischemic stroke. However, due to the incomplete comprehension of this phenomenon and the limited available data, secondary stroke prevention in such high-risk patients represents a clinical dilemma. There are several available strategies to prevent ischemic stroke recurrence in AF patients with breakthrough stroke in the absence of competing causes unrelated to AF, and these include continuation or change in the type of OAC, addition of antiplatelet therapy, left atrial appendage closure, or any combination of the above options. However, due to the limited available data, the latest guidelines do not provide any specific recommendations about which of the above strategies may be preferred. This review describes the incidence, the clinical impact and the potential mechanisms underlying OAC failure in AF patients. Furthermore, the evidence supporting each of the above therapeutic options for secondary stroke prevention and the potential future directions will be discussed.
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Affiliation(s)
- Roberto Galea
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
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Admission Severity of Atrial-Fibrillation-Related Acute Ischemic Stroke in Patients under Anticoagulation Treatment: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11123563. [PMID: 35743633 PMCID: PMC9225527 DOI: 10.3390/jcm11123563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 02/04/2023] Open
Abstract
Background: In non-valvular-associated atrial fibrillation (AF), direct oral anticoagulants (DOAC) are as effective as vitamin K antagonists (VKA) for the prevention of acute ischemic stroke (AIS). DOAC are associated with decreased risk and severity of intracranial hemorrhage. It is unknown if different pre-admission anticoagulants impact the prognosis of AF related AIS (AF-AIS). We sought to analyze the literature to assess the association between pre-admission anticoagulation (VKA or DOAC) and admission severity of AF-AIS. Methods: A Systematic literature search (PubMed and ScienceDirect) between January 2011 to April 2021 was undertaken to identify studies describing the outcome of AF-AIS. Results: A total of 128 articles were identified. Of 9493 patients, 1767 were on DOAC, 919 were on therapeutical VKA, 792 were on non-therapeutical VKA and 6015 were not anticoagulated. In comparison to patients without anticoagulation, patients with therapeutical VKA and under DOAC presented with less severe stroke (MD −1.69; 95% CI [−2.71, −0.66], p = 0.001 and MD −2.96; 95% Cl [−3.75, −2.18], p < 0.00001, respectively). Patients with non-therapeutical VKA presented with more severe stroke (MD 1.28; 95% Cl [0.45, 2.12], p = 0.003). Conclusions: In AF-AIS, patients under therapeutical VKA or DOAC have reduced stroke severity on admission in comparison to patients without any anticoagulation, with higher magnitude of protection for DOAC.
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Brízido C, Ferreira AM, Lopes P, Strong C, Sá Mendes G, Fernandes Gama F, Durazzo A, Rocha Rodrigues G, Matos D, Guerreiro S, Madeira S, Ferreira J, Adragão P, Mendes M. Medication adherence to direct anticoagulants in patients with non-valvular atrial fibrillation - A real world analysis. Rev Port Cardiol 2021; 40:669-675. [PMID: 34503705 DOI: 10.1016/j.repce.2021.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/08/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) changed the landscape of atrial fibrillation (AF) treatment, but also brought with them new challenges in terms of accessibility and compliance. The purpose of this study was to assess adherence to DOACs, and its determinants in a population of AF patients. METHODS Single-center retrospective study including all patients with non-valvular AF treated with a DOAC from the outpatient general cardiology list at a tertiary center, whose first DOAC prescription was between 1 April 2016 and August 2018. The number of pharmacy refills from the day of first prescription to 31 August 2018 was counted (by means of an electronic prescription platform). Medication refill adherence (MRA) was calculated by dividing the total days' supply by the number of days under therapy. Non-compliance was defined as MRA <90%. RESULTS A total of 264 patients (120 men, mean age 74 ± 12 years) met the inclusion criteria. The median CHA2DS2VASC score was 3 (interquartile range (IQR) 2-5) and the median HAS-BLED was 1 (IQR 1-2). Rivaroxaban, apixaban, dabigatran and edoxaban were prescribed in 45%, 41%, 24% and 13% of patients, respectively. During the study 51 patients (19%) used at least two DOACs .Patients took DOACs for a median period of 439 days (IQR 269-638), during which the included population adhered to therapy 90% of the time (IQR 75-100%). Half of the patients (51%) were classified as non-compliant; therapy duration (adjusted odds ratio 1.06 per month, 95% confidence interval (CI) 1.03-1.08, p<0.001), DOACs twice daily (adjusted OR 1.73, 95%CI 1.08-2.75, p=0.022), and higher out-of-pocket costs (adjusted OR 2.13, 95%CI 1.28-3.45, p=0.003) were independent predictors of non-compliance. CONCLUSION Half of the patients (51%) were classified as non-compliant (medication refill adherence <90%). Therapy duration, DOACs twice daily and higher out out-of-pocket costs were independent predictors of non-compliance, which could be targets to improve patient adherence.
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Affiliation(s)
- Catarina Brízido
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal.
| | - António Miguel Ferreira
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro Lopes
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Christopher Strong
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Gustavo Sá Mendes
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Francisco Fernandes Gama
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Anaí Durazzo
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Gustavo Rocha Rodrigues
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Daniel Matos
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Sara Guerreiro
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Sérgio Madeira
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Jorge Ferreira
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro Adragão
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Miguel Mendes
- Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
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Brízido C, Ferreira AM, Lopes P, Strong C, Mendes GS, Gama FF, Durazzo A, Rodrigues GR, Matos D, Guerreiro S, Madeira S, Ferreira J, Adragão P, Mendes M. Adesão à terapêutica com anticoagulantes diretos em doentes com fibrilhação auricular não valvular – uma análise de mundo real. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Vianna MS, da Silva Praxedes MF, de Araújo VE, Ferreira CB, de Sousa WJFN, Viana CC, Martins MAP. Self-report instruments for assessing adherence to warfarin therapy: a systematic review. Eur J Clin Pharmacol 2021; 77:1765-1781. [PMID: 34292359 DOI: 10.1007/s00228-021-03168-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The assessment of adherence to warfarin therapy is useful in clinical practice due to its wide variability in dose-response and risks of complications. The aim of this study was to investigate validated instruments used to assess adherence to warfarin therapy. METHODS Information was collected from the MEDLINE (PubMed), LILACS, EMBASE, and Cochrane Library databases. Search strategies were applied for each database, with no time limit or language restriction. Inclusion criteria consisted of study participants of ≥ 18 years of age, from both sexes, on chronic anticoagulation with warfarin for any indication and the use of validated instruments to assess adherence to warfarin therapy. Exclusion criteria consisted of duplicate articles, narrative or systematic reviews, and meta-analyses, as well as case reports/series and experimental studies involving animals. Two independent reviewers performed the following steps: evaluation of titles/abstracts, selection of studies after full reading, data extraction, and evaluation of potential bias. Discrepancies were resolved by a third reviewer. RESULTS Overall, 19 articles were selected for this systematic review, including 17 cross-sectional studies, one cohort study, and one quasi-experimental study, published from 2009 to 2019. The validated instruments identified in this review were Morisky Medication Adherence Scale (MMAS), the eight-item Morisky Medication Adherence Scale (MMAS-8), Measurement of Treatment Adherence (MTA), and Brief Medication Questionnaire (BMQ). Only MMAS-8 was tested for reliability, using the internal consistency assessment, with Cronbach's α range 0.56-0.71. CONCLUSIONS This review highlighted a gap in knowledge regarding the scarcity of validated instruments to assess adherence to warfarin therapy. Limitations were found in instruments that comprised the assessment of the isolated use of medication and the lack of analysis of other relevant therapeutic aspects. Future studies are needed to develop and validate more comprehensive instruments in an attempt to assess adherence to warfarin therapy. PROSPERO Registration number CRD42019128324.
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Affiliation(s)
- Mayara Sousa Vianna
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, MG, 31270-901, Brazil
| | - Marcus Fernando da Silva Praxedes
- Centro de Ciências da Saúde, Universidade Federal Do Recôncavo da Bahia, Av. do Cajueiro, Cajueiro, Santo Antonio de Jesus, BA, Brazil
| | - Vânia Eloisa de Araújo
- Faculdade de Odontologia, Pontifícia Universidade Católica de Minas Gerais, Av: Dom José Gaspar, 500 Coração Eucarístico, Belo Horizonte, MG, 30535-901, Brazil
| | - Carolina Barbosa Ferreira
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, MG, 31270-901, Brazil
| | - Waleska Jaclyn Freitas Nunes de Sousa
- Faculdade de Medicina da, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Bairro Santa Efigênia, Belo Horizonte, MG, 30130-100, Brazil
| | - Catiane Costa Viana
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, MG, 31270-901, Brazil
| | - Maria Auxiliadora Parreiras Martins
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, MG, 31270-901, Brazil.
- Faculdade de Medicina da, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Bairro Santa Efigênia, Belo Horizonte, MG, 30130-100, Brazil.
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Oliveira GMMD, Fontes-Carvalho R, Gonçalves L, Cardim N, Rochitte CE. The top 10 original articles published in the Brazilian Archives of Cardiology and in the Portuguese Journal of Cardiology in 2019. Rev Port Cardiol 2020; 39:115-121. [PMID: 32376062 DOI: 10.1016/j.repc.2020.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Glaucia Maria Moraes de Oliveira
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil; Instituto do Coração Edson Saad, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Ricardo Fontes-Carvalho
- Departamento de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Departamento de Cirurgia e Fisiologia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
| | - Lino Gonçalves
- Departamento de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | | | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil; Hospital do Coração (HCOR), São Paulo, SP, Brasil
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Oliveira GMMD, Fontes-Carvalho R, Gonçalves L, Cardim N, Rochitte CE. The top 10 original articles published in the Brazilian Archives of Cardiology and in the Portuguese Journal of Cardiology in 2019. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Bonhorst D. Acidentes tromboembólicos em doentes com fibrilhação auricular sob anticoagulação. Rev Port Cardiol 2019; 38:125-127. [DOI: 10.1016/j.repc.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Thromboembolic events in patients with atrial fibrillation under anticoagulation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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